Acupuncture for shoulder pain: Cochrane systematic review
Assessed as up to date: 2005/02/22
There are many commonly employed forms of treatment for shoulder disorders. This review of acupuncture is one in a series of reviews of varying interventions for shoulder disorders including adhesive capsulitis (frozen shoulder), rotator cuff disease and osteoarthritis. Acupuncture to treat musculoskeletal pain is being used increasingly to confer an analgesic effect and to date its use in shoulder disorder has not been evaluated in a systematic review.Objectives
To determine the efficacy and safety of acupuncture in the treatment of adults with shoulder pain.Search strategy
The Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL were searched from inception to December 2003, and reference lists from relevant trials were reviewed.Selection criteria
Randomised and quasi-randomised trials, in all languages, of acupuncture compared to placebo or another intervention in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica, cervically referred pain and fracture.Data collection and analysis
Two reviewers independently extracted trial and outcome data. For continuous outcome measures where the standard deviations were not reported it was either calculated from the raw data or converted from the standard error of the mean. If neither of these was reported, authors were contacted. Where results were reported as median and range, the trial was not included in the meta-analysis, but presented in Additional Tables. Effect sizes were calculated and combined in a pooled analysis if the study end-points population and intervention were homogenous. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis to indicate effect of acupuncture across all shoulder disorders.Main results
Nine trials of varying methodological quality met the inclusion criteria. For all trials there was poor description of interventions. Varying placebos were used in the different trials. Two trials assessed short-term success (post intervention) of acupuncture for rotator cuff disease and could be combined in meta analysis. There was no significant difference in short-term improvement associated with acupuncture when compared to placebo, but due to small sample sizes this may be explained by Type II error. Acupuncture was of benefit over placebo in improving the Constant Murley Score (a measure of shoulder function) at four weeks (WMD 17.3 (7.79, 26.81)). However, by four months, the difference between the acupuncture and placebo groups, whilst still statistically significant, was no longer likely to be clinically significant (WMD 3.53 (0.74, 6.32)). The Constant Murley Score is graded out of 100, hence a change of 3.53 is unlikely to be of substantial benefit. The results of a small pilot study demonstrated some benefit of both traditional and ear acupuncture plus mobilization over mobilization alone. There was no difference in adverse events related to acupuncture when compared to placebo, however this was assessed by only one trialAuthors' conclusions
Due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. There is a need for further well designed clinical trials.
Green Sally, Buchbinder Rachelle, Hetrick Sarah E
Acupuncture for shoulder pain
Does acupuncture work for treating shoulder pain?
To answer this question, scientists found and analyzed 9 research studies. The studies tested over 500 people who had shoulder pain. People had either acupuncture, a placebo (fake therapy), ultrasound, gentle movement or exercises usually for 20-30 minutes, two to three times a week for 3 to 6 weeks. Even though the studies were small and not of the highest quality, this Cochrane review provides the best evidence we have today.
What causes shoulder pain and how can acupuncture help?
Shoulder pain can be caused by a number of different conditions. It can be caused by rotator cuff disease, periarthritis or adhesive capsulitis (frozen shoulder). Shoulder pain can sometimes go away on its own but may last up to 12 to 18 months. Drug and non-drug treatments are used to relieve pain and/or swelling. Acupuncture is a non-drug therapy being used more and more to treat shoulder pain. It is thought that acupuncture works either by releasing chemical compounds in the body that relieve pain, by overriding pain signals in the nerves or by allowing energy (Qi) or blood to flow freely through the body. It is not known whether acupuncture works or is safe.
How well does acupuncture work?
The improvements with acupuncture for pain and function were about the same as the effects of receiving a fake therapy for 2 to 4 weeks.
One study showed that acupuncture improved shoulder function more than fake therapy after 4 weeks. But after 4 months, improvements were about the same with only an improvement of 4 more points on a scale of 0 to 100 with acupuncture.
One small study showed that acupuncture plus exercise was better than just exercise for improving pain, range of motion and function for up to 5 months.
How safe is it?
Side effects were not measured in many of the studies. One study showed that side effects such as fainting, headache, dizziness, swelling or leg weakness, were about the same with acupuncture or fake therapy.
What is the bottom line?
There is not enough evidence to say whether acupuncture works to treat shoulder pain or whether it is harmful.
From the little evidence that there is, acupuncture may improve pain and function over the short term (2 to 4 weeks).
Implications for practice
Due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to either support or refute the use of acupuncture for treating shoulder pain and more trials are needed. The limited evidence available indicates some short term benefit of acupuncture compared to placebo with respect to shoulder specific disability. Little is known of the potential for adverse effects.
Implications for research
Systematic reviews and meta-analyses of randomised controlled trials serve to identify areas of clinical practice where further research is required. When sound conclusions about efficacy cannot be made after this process, there is a need for methodologically sound randomised controlled trials to justify or censure current treatment strategies.
One trial included in this review developed an appropriate placebo for use in acupuncture trials which may inform future trials.
Further trials should consider assessing the effect of acupuncture when combined with other modalities, define study population by clear diagnostic criteria, use standardised outcome measures for disability and pain, be adequately powered, follow up participants to determine longer term outcome and give consideration to adverse effect.Get full text at The Cochrane Library
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